Postoperative pain management for Nurses

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1. Dr. Tushar B Munnoli, MD CIPS Consultant Pain Specialist, Apollo Hospitals, Jubilee Hills, Hyderabad. POST-OPERATIVE PAIN ASSESSMENT & MANAGEMENT Fellowship in Chronic Pain Management. Certified Interventional Pain Sonologist (CIPS), World Institute of Pain (USA). Post-doctoral fellowship in Regional Anesthesia & Pain Management (AORA). Diploma in Musculoskeletal Ultrasound. GC Member - Indian Society for Study of Pain (ISSP). Founding member - Musculoskeletal Pain & Ultrasound Society.

2. Vital signs? P ain is perceived as a consequence of Surgery and often the pain sufferers are asked to live with it. Pain can be managed.

3. Introduction: Pain management is recognized as an important indicator of standards of accreditation in health and quality of health care. Effective postoperative pain control is an essential & humanitarian need of every surgical procedure. Postoperative pain is still undermanaged. - due to insufficient education, fear of complications associated with available analgesic drugs, poor pain assessment,

4. What is Pain? A vital function of the nervous system in providing the body with a warning of potential or actual injury.

5. PAIN PATHWAYS The pain pathway/nociceptive pathway - a complex network of nerves and structures responsible for transmitting and processing pain signals throughout the body. Understanding of this is essential for comprehending how pain is perceived and managed.

6. PAIN PATHWAYS S equence of events that are involved in the neural processing of noxious stimuli : Transduction, Transmission, Perception. Modulation.

7. PAIN PATHWAYS Modulation Can either facilitate or inhibit pain.

8. PAIN PATHWAYS Modulation The evidence for pain modulation was first recorded by a physician serving the US Army during World War II “Strong emotions" block pain. Many variables interplay with the experience of pain, including memory , mood, environment, attention, and expectation.

9. A strongly held misconception! “acute pain vanishes in a few days, and as long as the operation was successful, the acute postoperative pain will soon be forgotten ”

10. The Pain Memory People may experience fear and anxiety if they have had a negative previous pain experience, if effective pain management is not provided, if their pain is not relieved, or if they have severe pain . On the other hand, if the pain the person experiences is effectively managed, the person can cope better with the pain ( Acar et al., 2016 ). PAIN PATHWAYS

11. PAIN PATHWAYS Modulation Mechanisms that act to inhibit pain transmission : Central Modulation Peripheral Modulation

12. PAIN PATHWAYS Modulation Gate control theory of Pain :

13. PAIN PATHWAYS Modulation

14. TYPES OF PAIN Based on time Based on mechanism

15. TYPES OF PAIN Based on time

16. TYPES OF PAIN Based on mechanism

17. POST-OPERATIVE PAIN Postoperative pain is considered a form of acute pain due to surgical trauma with an inflammatory reaction and initiation of an afferent neuronal barrage. It is a combined constellation of several unpleasant sensory, emotional and mental experience precipitated by the surgical trauma and associated with autonomic, endocrine-metabolic, physiological and behavioral responses.

18. POST-OPERATIVE PAIN - Incidence Every year, millions of people undergo surgery and experience postoperative pain at various levels. Nearly three-quarters of patients undergoing surgical interventions have acute pain, and 20% to 80% of postoperative patients experience pain. (Gan, 2017; Meissner et al., 2018).

19. Biological responses to tissue injury What happens after Surgery?

20. GOALS OF POST-OPERATIVE PAIN MANAGEMENT To provide continuous effective analgesia that is safe and free from unwanted side effects. Facilitate rapid recovery and return to full function. Prevent complications and reduce morbidity. Allow early discharge from the hospital. Prevention of chronic pain. Improve the quality of life for the patient.

21. TEAM MEMBERS POST-OPERATIVE PAIN MANAGEMENT Communicate effectively to keep the team informed and organized. Make rapid decisions about appropriate care interventions. Communicate with patients, families, and other members of the healthcare team to ensure seamless care delivery.

22. ASSESSMENT OF PAIN Pain assessment should be ongoing, individualized, and documented. Subjective and Objective methods are two different approaches to gather information. Question the patient Use pain rating scales Evaluate behavior & physiologic signs Secure family’s involvement Take action and assess effectiveness

23. ASSESSMENT OF PAIN PAIN HISTORY – OPQRSTU O nset:  “Did your pain start suddenly or gradually get worse and worse?” P rovokes or P alliates:  “What makes your pain better or worse?” Q uality:   “What words would you use to describe your pain?” or “What does your pain feel like?” R adiates:   “Point to where it hurts the most. Where does your pain go from there?” S everity:  Pain is subjective and relative to each patient you treat. Have an open mind for any response from 0 to 10. T ime:   Intermittent/continuous/time of the day

24. ASSESSMENT OF PAIN Clinical examination: Pain diagram General physical examination Musculoskeletal examination Neurological examination Other systems

25. ASSESSMENT OF PAIN PAIN ASSESSMENT

26. ASSESSMENT OF PAIN PAIN ASSESSMENT – Unidimensional tool NUMERICAL RATING SCALE ≥ 4 out of 10 INTERVENTION IS REQUIRED - A change in the NRS of 20% between two time-points of an assessment is regarded as being clinically significant. Easy to use. Simple to describe. High rate of adherence. Flexible administration (including by telephone) Less reliable for some patients (very young or old; patients with visual, hearing, or cognitive impairment)

27. ASSESSMENT OF PAIN PAIN ASSESSMENT – Unidimensional tool VISUAL ANALOG SCALE Efficient to administer. Valid in patients with chronic pain, older than age 5 years, rheumatic disease. -Time-consuming scoring -Controversial validity -Can cause patient confusion -Poor reproducibility with cognitive dysfunction

28. ASSESSMENT OF PAIN PAIN ASSESSMENT – Unidimensional tool WONG-BAKER FACES PAIN RATING SCALE Perceived as easier than NRS or VAS. Useful in individuals with difficulty communicating (e.g., children, elderly, individuals with limited language fluency or education). - Potential for distorted assessment (i.e., patients' tendency to point to the center of such scales) Ask the person to choose the face that best describes how he is feeling.

29. ASSESSMENT OF PAIN PAIN ASSESSMENT – Multidimensional tool MCGILL PAIN QUESTIONNAIRE (MPQ) Extensively tested. Assesses sensory and affective dimensions of pain. Short form takes only 2-3 minutes. - Total score, but not individual scale scores, is considered valid measure of pain severity.

30. ASSESSMENT OF PAIN PAIN ASSESSMENT – Special Population BEHAVIORAL PAIN SCALE (BPS) To assess pain in patients who are unable to communicate verbally . Each category is scored on a scale from 1 to 4, with higher scores indicating more severe pain-related behaviors. The total score ranges from 3 to 12. Painless (3), mild (4–6), moderate (7–9), or severe (10–12) pain. ≥ 7 out of 12 INTERVENTION IS REQUIRED

31. ASSESSMENT OF PAIN PAIN ASSESSMENT – Special Population FLACC Pain Scale An observational pain scale Was designed for neonates at 2 months, may be useful up to 7 years of age. However, in adult settings may use the FLACC pain scale for people who are unable to communicate their pain.. ≥ 4 out of 10 INTERVENTION IS REQUIRED

32. ASSESSMENT OF PAIN PAIN ASSESSMENT – Special Population NEONATAL INFANT PAIN SCALE (NIPS) Used in children less than one year of age. The scale typically assesses six behavioral and physiological parameters. ≥ 4 out of 10 INTERVENTION IS REQUIRED

33. POST-OPERATIVE PAIN MANAGEMENT

34. POST-OPERATIVE PAIN MANAGEMENT

35. POST-OPERATIVE PAIN MANAGEMENT Multimodal analgesia involves the use of a combination of analgesic medications with different mechanisms of action to provide synergistic pain relief while minimizing side effects.

36. POST-OPERATIVE PAIN MANAGEMENT

37. POST-OPERATIVE PAIN MANAGEMENT OILS check: following a standardized procedure for pump programming and checking of infusions. Orders, Infusions, Lines and Securement (OILS). The position of the epidural catheter. The motor block ( bromage ). Assessment of the effectiveness of the epidural catheter

38. POST-OPERATIVE PAIN MANAGEMENT Complications related to epidural catheter insertion – Headache (post dural puncture headache). Back pain: This is usually at the insertion site; it is common and transient. Moderate to severe back pain must be reported urgently for investigation. Complications related to epidural drugs - Overdose/toxicity: Signs of LA toxicity are dizziness, blurred vision, decreased hearing, restlessness, tremor, hypotension, bradycardia, arrhythmia, seizures, and sudden loss of consciousness. Cease the RA infusion. May require resuscitation and management of cardiac, neurological and respiratory side effects. Assessment of the effectiveness of the epidural catheter

39. POST-OPERATIVE PAIN MANAGEMENT Complications related to pain Assess dermatomes, if there has been a receding block an epidural bolus may be required and the infusion rate may need to be increased. The first line analgesia is an epidural bolus before administration of other analgesia. Check if the epidural catheter become disconnected, if the epidural catheter been dislodged, or if the epidural infusion is leaking. Assessment of the effectiveness of the epidural catheter

40. POST-OPERATIVE PAIN MANAGEMENT Assessment of the effectiveness of the Peripheral nerve block catheter.

41. POST-OPERATIVE PAIN MANAGEMENT Assessment of the effectiveness of the Peripheral nerve block catheter.

42. SUMMARY

43. You truly are the superhero for patients in pain! THANK YOU!